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PROOF OF INSURANCE (2022 - 2022) CLOSEDS&SLA-1 OP t E ,4coR .mm CERTIFICATE OF LIABILITY INSURANCE DATE/Y (MMIDDYYY) 1210912021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement's PRODUCER 877-242-9600 c ACT Central Insurance Agency Central Insurance Agency, Inc. PHONE 877 242-9600 FAX 877 243 8995 93 East Main Street INC No, Ext) (AIC Noi Smithtown, NY 11787 E~M a certificates clainsures com Stephen Ormsby+sS -.- Force, Inc DBA JRM flop aue't Canyon Rd. #413 us, F: Peleus Insurance COMDanv }34118 A T'ht1CJ"1 A. ACC: AMMYIC'MA'A Y= kti uawet 'M. or-WIA.4IARl. IUIIIIAI,t'.I01 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, .-..-.-.-.. ry ...... TYPE OF INSURANCE . ............... i Y.. INSR ,/1DDL SUBR POLIC NUMBER ,.......... ..,,,,,. „......... POLICY EFF =POLI'IMMIDCY EXP LIMITS A 1 X COMMERCIAL L LIABILITY 1 EACH QCCIIRRENC 1,000,000 CLAIMS -MADE X occuR X �GLV0001060 DAMAGE TORENTED 08I30/2021 08/30/2022 PREM15BS dEa 9;r.v f.PnC9) 250,000 .. It &Bat Assault X Battery 1 MED,FXP„Anyonape�sorri ................. 5000 , .te Profession X SSIOfIaI Llab ....,. ..... 1 1,000,000 -.-.-.-.. .. GE�1 LIMIT APPLIES PER. GENERAL 1 S , .. m... 3,000,000 .. -- - PET LOC i...PRODUCTS„ COMP/OP AGG .,... .3,000,000 POLIO I 1 A UTOMOBILE LIABILITY 1 1 COMBINED SINGLE LIMIT (�F rt7G�11'I� --- ANY AUTO BODILY URY (Perp2rSon) 1 OWNED SCHEDULED AUTOS ONLY AUTOSD .5., BODILY INJURY Per arcident� 8 Hpp#°' NDNN : qq �..d.PeOP�Y ntAMAGE--- $...... ,...... ....� ALP S ONLY AUT0 Of I,'tl � � � I ...f A X i UMBRELLA un6 X OCCURUMV0000262 C IMS M EXCEXI� 08/30/2021 08/30/2022A�r OC GIJRRENC P $ 5,000,000, 5,000,000, SSB �10 A00 AGGREGATE ...m. , DED RETENTIONS € S WORKERS COMPENSATION JAND EMPLOYERS' LIABILITY YIN ' SEATU 1 ..ERN f hY PROPRIETOR/PARTNER/EXECUTIVE, f6,F CL,pp�fP MBER EXCLUDED? NIA E I EACH A CCIDENT 5 """ "' ® "' -" MaAgakor'y m NH) d„..P L DISEASE EA EMPLOYEE' `h ------------- If yes, describe under DESCRIPTION OF OPERATIONS below E I. P E.A.-E • POLICY LgWT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The City of EI Segundo its officers, officials, employees agents, and volunteers are includej as an addltlonal insured under the general liability With respect to the liability created la the negligent acts, errors and omissions of the named insured erein as required by Written contract. THECIEL The City of El Segundo 3501 Main st El Segundo, CA 90425 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: GLV0001060 COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL AL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following; COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Location(s) Of Covered Operations The City of El Segundo, its officers, officials, employees, Automatic Status Included Where Required by lagents and volunteers. Written Contract. Information required to complete this Schedule, if not shown above, will be shown in the Declarations A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) desig- nated above. B. With respect to the insurance afforded to these additional insureds, the following additional exclu- sions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equip- ment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor en- gaged in performing operations for a principal as a part of the same project. CG 20 10 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 0 POLICY NUMBER: GLV0001060 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Or anization(sy Location And Description Of Completed Operations FTThh—.eCity of El Segundo, its officers, officials, employees, Automatic Status Included Where Required by Written agents and volunteers. Contract. E Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property dam- age" caused, in whole or in part, by "your work" at the location designated and described in the sched- ule of this endorsement performed for that additional insured and included in the "products -completed operations hazard". CG 20 37 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 0 CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 11 /15/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT DARIN TSUKASHIMA NAME: t rarilf DARIN TSUKASHIMA PHONE 661 260 1400 FAX Nct 661 260 2787 AC No,,9x0t STATE FARM INSURANCE E MAtL DARIN@DARINTSUKASHIMA COM 26650 THE OLD ROAD SUITE 205 INSURER SAFFORDING COVERAGE NAIC # VALENCIA CA 91381 INSURER A, State Farm Mutual Automobile Insurance Company 25178 INSURED S & S LABOR FORCE, INC 26893 BOUQUET CANYON RD # 413 SAUGUS CA 91350-3500 COVERAGES CERTIFICATE NUMBER- REVISION NUMBER - THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, ww,, l4sR AODL,$ LTR TYPE OF INSURANCE FbISD'WVDPOLICY NUMBER fMM/DOfYYYY f IM,.Ippry YY LIMITS COMMERCIAL GENERAL LIABILITY '.. EACH OCCURRENCE $ �..a P7AMA;( 'Y-ORE TEb ,.....,, ®; CLAIMS -MADE OCCUR REMISE,S,..(Ea occyTre:nce-) ''. $ ._.... '... '.... " MED EXP (Any one person) S '.. '.. PERSONAL & ADV INJURY $ AGGREGATE LIMIT APPLIES PER:', GENERAL AGGREGATE $ '.. POLICY JECTPRO '... LOC " PRODUCTS - COMP/OP AGG S ] OTHER. AUTOMOBILE LIABILITY Y 6780555-A06-75 07/06/2021 01/06/2022 COMBINED SINGLE LIMI (Ea acx: don $ 1,000,000 xANY AUTO : 678 0556-A06-75 BODILY INJURY (Per person) 07/06/2021 01/06/2022 ...... S ........ ...., .,, OWNED SCHEDULED ABODILY B INJURY (Per accident) $ AUTOS ONLY �,,,,,,,, AUTOS HIRED NON -OWNED 673 5870- 05-75 -07/06/202101/06/2022 PRO'1aCvd'N...DAWraA,GE . AUTOS ONLY ':. AUTOS ONLY tPt.r,accadr<aw,G] S - S UMBRELLA LIAB OCCUR EACH OCCURRENCE ...,E .... ..:.. .. . S ......._ EXCESS LIAB CLAIMS -MADE '.. '.. AGGREGATE S DED RETENTION WORKERS COMPENSATION PER OTH AND EMPLOYERS' LIABILITY Y F N TI,7f. ""'"'" _ R ­ ,"- .,,.,, ANY PROPRIETOR/PARTNERIEXECUTIVE "" E L, EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? NIA "'""" '""" (Mandatory in NH) :., E L DISEASE - EA EMPLOYEE $ If yes, describe under ... '.. DESCRIPTION OF OPERATIONS below E L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The City of El Segundo, its officers, officials, employees, agents, and volunteers are listed as an additional insured under the auto policy. Policies on an automatic renewal from previous term. CERTIFICATE HOLDER The City of El Segundo 350 Main St. El Segundo, CA 90245 ACORD 25 (2016/03) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Completed by an authorized State Farm representative. If signature is required, please contact a State Farm agent. @ 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 1001486 132849.13 04-22-2020 ~ DATE(MM/DD/YYYY) ACCOR" CERTIFICATE OF LIABILITY INSURANCE ,w 11I15/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Melinda Sylvester ................................._ ... .......................................................... .._ .. .n. .... Hays Companies Inc, PHONE (909) 243 8120 SAX A/MArL,No ,Ext,) ..... ... .......... 4200 Concours, Suite #350 msylvester@hayscompani ADDRESS: es,com INSURERS) AFFORDING COVERAGE NAIC # Ontario CA 91764 INSURERA: State Compensation Ins Fund 35076 .. ........................ INSURED ...-... INSURER B : S&S Labor Force, Inc,, DBA: JRM INSURER C : 26893 Bouquet Canyon Rd. #413 INSURER D : INSURER E : Saugus CA 91350 INSURER F: COVERAGES CERTIFICATE NUMBER. 21-22 WC REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CR R TYPE OF INSURANCE ........... NNSD. VIY D POLICY NUMBER MMIDDYYY MM O/Y DYYY LIMITS.. COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 5 CLAIMS -MADE EOCCUR N N N N PREMISES (Ea occur Pnce) S .. AGGREGATE LIMITAPPLIES PER: POLICY E PRO ❑ LOC JEC"{. AUTOMOBILE LIABILITY ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED ---- AUTOS ONLY AUTOS ONLY UMBRELLA LIAB I�,... OCCUR EXCESS LIAB f CLAIMS -MADE i7�Y7I�� 7�Y�lYYCi7�iER AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE A OFFICER/MEMBER EXCLUDED? Y N/A (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below MED EXP (Any one person) S '. PERSONAL&ADV INJURY S GENERALAGGREGATE s PRODUCTS - COMP/OP AGG S $ COMBINED SINGLE LIMIT '., Eaacociun4.e ........................... BODILY INJURY (Per person) s - BODILY INJURY (Per accident) ....... _......... S PROPER`rY DAMAGE I $ WW Per accident) .,..mm 5 EACH OCCURRENCE S AGGREGATE _ S S 9223920-2021 01 /05/2021 01 /05/2022 E. L. EACH ACCIDENT s 1.000.000 E.L. DISEASE- EA EMPLOYEE ''.. $ 1.000.000 E. L. DISEASE -POLICY LIMIT S 1.000,000 DESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Evidence of Coverage t.+tK I'.. Ir IL.A It %4,$t,,.I.ltK LAIYI.GLLA11V14 The City of El Segundo 3501 Main Sreet ElSegundo CA 90425 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD ENDORSEMENT AGREEMENT STATE COMPENSATION WAIVER OF SUBROGATION REP 06 INSURANCE ® 9223920-21 FUN RENEWAL SP HOME OFFICE 6-05-32-02 SAN FRANCISCO PAGE 1 OF 1 ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC EFFECTIVE NOVEMBER 18, 2021 AT 12.01 A.M. STANDARD TIME OR THE TIME INDICATED AT AND EXPIRING JANUARY 5, 2022 AT 12.01 A.M. PACIFIC STANDARD TIME S&S LABOR FORCE, INC. 26893 BOUQUET CANYON RD. SUITE 413 SAUGUS, CA 91350 ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING, IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND WAIVES ANY RIGHT OF SUBROGATION AGAINST, CITY OF EL SEGUNDO WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS POLICY IN CONNECTION WITH WORK PERFORMED BY, S&S LABOR FORCE, INC. IT IS FURTHER AGREED THAT THE INSURED SHALL MAINTAIN PAYROLL RECORDS ACCURATELY SEGREGATING THE REMUNERATION OF EMPLOYEES WHILE ENGAGED IN WORK FOR THE ABOVE EMPLOYER. IT IS FURTHER AGREED THAT PREMIUM ON THE EARNINGS OF SUCH EMPLOYEES SHALL BE INCREASED BY 03%. NOTHING IN THIS ENDORSEMENT SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS ABOVE STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS IN THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: NOVEMBER 24, �l2021 2570 AUTHORIZED REPRESENT ' IVE PRESIDENT AND CEO SCIF FORM 10217 (REV.4-2018) OLD OF 217